The Open Ophthalmology Journal, 2012, 6, 65-72

65

Open Access

Optic Neuritis, its Differential Diagnosis and Management

Hedieh Hoorbakht and Farid Bagherkashi*
Bharati Vidyapeeth University, Medical College, School of Optometry, Pune, Maharashtra, India
Abstract: The aim of this review is to summarize the latest information about optic neuritis, its differential diagnosis and
management. Optic Neuritis (ON) is defined as inflammation of the optic nerve, which is mostly idiopathic. However it
can be associated with variable causes (demyelinating lesions, autoimmune disorders, infectious and inflammatory
conditions). Out of these, multiple sclerosis (MS) is the most common cause of demyelinating ON. ON occurs due to
inflammatory processes which lead to activation of T-cells that can cross the blood brain barrier and cause
hypersensitivity reaction to neuronal structures. For unknown reasons, ON mostly occurs in adult women and people who
live in high latitude. The clinical diagnosis of ON consists of the classic triad of visual loss, periocular pain and
dyschromatopsia which requires careful ophthalmic, neurologic and systemic examinations to distinguish between typical
and atypical ON. ON in neuromyelitis optica (NMO) is initially misdiagnosed as ON in MS or other conditions such as
Anterior Ischemic Optic Neuropathy (AION) and Lebers disease. Therefore, differential diagnosis is necessary to make a
proper treatment plan. According to Optic Neuritis Treatment Trial (ONTT) the first line of treatment is intravenous
methylprednisolone with faster recovery and less chance of recurrence of ON and conversion to MS. However oral
prednisolone alone is contraindicated due to increased risk of a second episode. Controlled High-Risk Subjects Avonex
Multiple Sclerosis Prevention Study CHAMPS, Betaferon in Newly Emerging Multiple Sclerosis for Initial Treatment
BENEFIT and Early Treatment of MS study ETOMS have reported that treatment with interferon
-1a,b results in
reduced risk of MS and MRI characteristics of ON. Contrast sensitivity, color vision and visual field are the parameters
which remain impaired mostly even after good recovery of visual acuity.

Keywords: Optic neuritis, differential diagnosis of optic neuritis, multiple sclerosis, neuromyelitis optica.
INTRODUCTION
The term optic neuritis (ON) refers to inflammation of
the optic nerve due to many causes, indicated by sub-acute
unilateral painful visual loss mostly in a young healthy
female and by excluding glaucoma, ON is the most common
optic neuropathy in persons under 50 years coming to
general ophthalmic practice. It is the earliest clinical
symptom in about 20% of cases of MS [1-5].
The gold standard treatment for ON is based on the Optic
Neuritis Treatment Trial (ONTT) which was undertaken in
order to determine the efficacy of corticosteroids and to
permit long-term analyses [1,6,7]. In the ONTT, 15 clinical
centers in the United States registered 457 patients between
July 1, 1988 and June 30, 1991 with the following criteria:
the presence of acute unilateral optic neuritis with visual
symptoms for 8 days or less, age between18 and 45 years, no
previous history of ON in the affected eye, no evidence of
systemic disease other than MS that might be associated with
the ON, and no previous treatment with corticosteroids for
MS or ON [1,6,7]. This article reviews available studies
published in English and Spanish regarding optic neuritis, its
differential diagnosis and management.
AETIOLOGY
ON is mainly idiopathic in nature; though, it could be related to demyelinating lesions (e.g. MS [4,8-10] neuromyelitis
*Address correspondence to this author at A7/503, 10 Elite Society, Kate
Puram Chowk, New Sangvi, Pimple Gurav, Pune 411027, Maharashtra,
India; Tel: +91-9604304202;
E-mails: farid_bagherkashi@yahoo.com, circleofunity9@yahoo.com
1874-3641/12

optica (NMO) [4,8,9]) or other less common etiologies such

as autoimmune disease (e.g. sarcoidosis [1,4,9], systemic
lupus erythematosus (SLE) [4,9]), infectious and parainfectious causes (e.g. syphilis [1,4,9,11], tuberculosis
[4,9,11]), inflammatory and post vaccination immunological
responses [4] (e.g. sinusitis [1], and vaccinations against
measles and rubella [12]). (Table 1)
PATHOPHYSIOLOGY
The pathogenesis of optic neuritis is not well understood.
It is likely due to some inflammatory process which leads to
delayed type IV hypersensitivity reaction induced by
released cytokines and other inflammatory mediators from
activated peripheral T-cells which can cross the blood brain
barrier and cause destruction of myelin, neural cell death and
axonal degeneration.
Latest technologies such as optical coherence
tomography (OCT) suggest involvement of axons (gray
matter) in addition to myelin sheath (white matter) in this
process [2,5,8,14].
Permanent visual loss (40%to 60%) and visual deficit in
ON is a result of axonal loss in the optic nerve and retina and
corresponding retinal nerve fiber layer (RNFL) thinning, in
addition to conduction block caused by demyelination of the
optic nerve [8,14,15].
CLINICAL FEATURES AND DIAGNOSIS
Based on the location of involvement, ON can be
categorized as: 1. retrobulbar neuritis (2/3 of cases) with
normal optic disc appearance; 2. papillitis with swollen disc;
2012 Bentham Open

66 The Open Ophthalmology Journal, 2012, Volume 6

Table 1.

Hoorbakht and Bagherkashi

Aetiology of Optic Neuritis

Demylinating
lesions

Multiple Sclerosis (MS) [4,8-10], Neuromyelitis optica [4,8,9], Shilders disease, Encephalitis periaxialis concentrica [4] (out of
which MS is the most common cause [4])

Autoimmune
Disease

Sarcoidosis [1,4,9], systemic lupus erythematosus (SLE) [4,9], Sjgrens syndrome (SS), Behchets disease [9]

Infectious/parainfectious

Herpes zoster [9], lyme disease [1,4,9], syphilis [1,4,9,11], tuberculosis, dengue [11,13], mumps, varicella zoster [4,11],
toxoplasmosis [4,9,11], measles [4,11,12], leptospirosis, chickungunya, west nile [11], adenovirus, brucellosis, coxsackievirus, cat
scratch disease,
-hemolytic streptococcal infection, meningococcal infection, typhoid fever, whipples disease [4]

Inflammatory/post
vaccination

sinusitis [1], vaccinations against tuberculosis, hepatitis B, rabies, tetanus, meningitis, anthrax, measles, rubella & influenza [12]

3. perineuritis, which involves the optic nerve sheath while

the optic disc may or may not be swollen;4. neuroretinitis
with optic disc oedema and macular star exudates.
Retrobulbar neuritis and papillitis are mainly associated
with MS while perineuritis and neuroretinitis are more often
associated with infectious or inflammatory pathologies
[1,2,4,8,16].
Based on its clinical features, ON can be classified as
atypical or typical which is present without any
manifestation of systemic disease and may occur either as a
clinically isolated syndrome or in association with MS
(Tables 2 and 3) [2,8,9].
The classic triad for diagnosis of ON is visual loss,
periocular pain and dyschromatopsia [2,5,9]. Optic neuritis
can have long-lasting effects on visual motion processing
regardless of temporary effects on visual form processing. In
the acute phase there is a much greater effect on motion
processing than form processing [20].
ON Associated with NMO (Devics disease) & MS
NMO is an acute inflammatory demyelinating disease
mainly involving the optic nerves and spinal cord. Optic
neuritis in NMO and MS are nearly identical in their initial
presentation. However, demyelinating NMO is more violent
and devastating than MS, hence its correct diagnosis is very
important (Table 4). In more than 85% of patients with
NMO, attack recurs in the form of ON, transverse myelitis
(TM), or both, resulting in around 50% of cases in paralysis
or blindness within 5 years. Sometimes patients with TM in
the cervical spine experience respiratory failure and even
death. Serum  






 





patients, and targets the water channel protein
aquaporin-4. The diagnosis of NMO requires two absolute
criteria and two of the three supportive criteria (Table 5)
[2,8,9,14,21].
MS is a demyelinating disease disseminated in time and
space i.e., the incidence of a second clinical episode at a
distinct site in the central nervous system (CNS). Absence of
common deficit along with lack of abnormal findings in MRI
or cerebrospinal fluid (CSF) exclude a diagnosis of MS
[12,18,21].
According to International Panel on Multiple Sclerosis
Diagnosis, MRI visualized dissemination of CNS lesions in
time and space is sufficient for the diagnosis of MS even
before occurrence of clinical symptoms [18].

Table 2.

Features of Typical ON in Adults

Acute to sub-acute onset [2,8] promoting over a several hours 6 to 2

weeks [2,9,10]

Young adult patient with peak manifestation between 15-50 years of

age [2,3,9]

Females > males [2,3,9]

Periocular pain (90%) [2,5,16-18], especially with eye movement

[2,3,8-10,18]

Unilateral loss of visual acuity [2,4,8-10,18] variable in severity

(from 20/20 in 10.5% to no light perception in 3.1% [4,5,16]), or
may be bilateral usually in children often associated with a post or
para infectious demyelination [2,4,8,10]

Reduced contrast sensitivity [1,8,9,18]

Uhthoffs phenomenon (Exercise or heat-induced deterioration of

visual symptoms) [2,5,8,18]

Pulfrich phenomenon (misperception of the direction of movement

of an object) [2,5,8,18]

Ipsilateral relative afferent pupillary defect (RAPD). lack of the

defect suggests a preexisting or concurrent optic neuropathy in the
fellow eye [2,4,8-10,18]

Normal (65%) or swollen (35%) (more common in children) optic

nerve head [2,5,9,10,18]

Possibility of mild uveitis [9,18] and retinal periphlebitis [2,9,18]

Visual field defect [2,4,10], any type [9,18]; ranging from

commonly seen diffuse depression and central or centrocecal
scotoma [2,5,8,16], to rarely seen quadrantic [2,4,16] and altitudinal
defects [4]

Spontaneous visual improvement in >90% [2,3,9,18]

No deterioration in vision after steroids discontinuation [2,9]

Pallor of the optic disc [2,11]

Previous history of ON or MS [9,18]

Reduction in vision in bright light [2]

Phosphenes or photopsias (spontaneous flashes of light in vision)

provoked by eye movement [8,18]

Dyschromatopsia [2,8-10,18] (any type) [2,7]*

*Demyelinating ON does not obey Kollner's rule:

Red-Green color vision defects are characteristic of optic nerve disease and blueyellow defects are characteristic of retinal disease (especially macular disease) [7,19].

Optic Neuritis, its Differential Diagnosis and Management

Table 3.

The Open Ophthalmology Journal, 2012, Volume 6

Age >50 or <12 years [2,9]

Simultaneous or sequential bilateral ON [2,4,9]

Severe visual loss (no light perception) which progress for >2 weeks
from onset [1,2,4,9]

Painless/painful/persistent pain > 2 weeks [2,4,9]

Abnormal ocular findings:

o
o
o
o
o
o

annual incidence of ON is estimated at 5 per 100,000. ON is

seen more commonly in Caucasians, and quite rarely in
black populations. Incidence of ON is eight times higher in
white northern Europeans than blacks and Asians. In Asia,
ON is proportionately more common, relative to the
incidence of MS in the USA or western Europe and is less
frequent in south America and Mediterranean region but
newer studies has reported an increasing prevalence in the
last few decades. Studies have shown that peoples who
migrate before puberty get the incidence of MS in the region
to which they migrate. So, a connection exists between
ethnicity and environment [1-4,8,9,25-28].

Features of Atypical ON in Adults

Noticeable anterior and/or posterior segment inflammation [2]

Significant uveitis [9] and retinal periphlebitis [2,9]
Intensely swollen optic nerve head [2,4,9]

DIFFERENTIAL DIAGNOSIS

Severe optic disc haemorrhages [1,2,5,9]

Retinal exudates [1,4,5]

Various forms of optic neuropathy mimic ON, resulting

in misdiagnosis. These include AION (Anterior ischemic
optic neuropathy) and LHON (lebers hereditary optic
neuropathy), which most closely resemble ON.
Toxic/metabolic causes and compressive optic neuropathies
should also be considered in the differential diagnosis of ON
[2,5,23].

Macular star [1]

Absence of any visual recovery within 3-5 weeks [2,4,9] or

continued exacerbation in visual function [2]

Lower risk of developing MS [4]

Manifestation of systemic diseases other than MS [2,9]

Deterioration in vision after steroids discontinuation [2,9]

Family history [2]

Previous history of neoplasia [2,9]

Optic atrophy lacking history of ON or MS [9]

PREVALENCE
Patients with acute demyelinating ON are typically
healthy young adults. Female preponderance in observed,
with a ratio of approximately 3:1. For reasons still unclear,
the incidence of MS associated with ON is highest in people
living at higher latitudes (e.g.in northern USA, northern and
western Europe; New Zealand and southern Australasia) and
reduce significantly closer to the equator. Studies have
reported a correlation between reduction in vitamin D (25hydroxyvitamin D) level and increased risk of
developing/relapsing MS. Therefore lower intensity and
lesser exposure to sunlight at high latitude may be an
explanation for epidemiological variations of MS. The
Table 4.

67

Anterior Ischemic Optic Neuropathy (AION) which

occurs in individuals over 50 years of age and equally
in males and females, is characterized by unilateral
sudden painless (pain is present in <10% of patients;
accompanied by headache in patients with temporal
arteritis) loss of vision, varying from visual acuity of
better than 6/6 to no light perception with impairment
of color vision and altitudinal visual field defect.
Crowded optic disc appears swollen with sectorial
haemorrhage and small or no cup in the fellow eye.
Most patients with ischemic optic neuropathy have
hypertension,
hypercholesterolemia,
diabetes
mellitus, obstructive sleep apnea, or other vascular
risk factors. AION has two major subtypes. Nonarteritic AION (NA-AION) is the most common
form. The visual loss in this subtype is considered to
be as a result of insufficient blood supply to the optic
nerve head. ON has a better prognosis than NAAION. Arteritic AION (A-AION) is more common in
females, starting with massive loss of vision, usually
due to giant cell arteritis, and has a significant

Differential Diagnosis of NMO vs MS

Features

Neuromyelitis Optica

Multiple Sclerosis

Attacks are bilateral

Usually [8,9]

Rarely [8]

Visual loss severity

More, with less improvement [8,10,14,22]

Less, with more improvement [9,22]

White matter lesions on brain MRI

Rarely and usually resolving [8,9]

Usually [8,22]

Transverse myelitis

TM in spinal MRI often spanning
3 spinal

cord segments (in 20%) [2,8,9,22]

Rarely [8]

Clinical involvement beyond spinal cord and optic nerve

Rarely [8]

Usually [8]

Tissue destruction and cavitations

More than MS [8]

Less than NMO [8]

Oligoclonal bands

Rarely [2,8,9]

Frequently [8,22]

Protein contents

Higher than MS [8]

Lower than NMO [8]

DMDs

Ineffective even worsening [8,9]

Effective [8,9,23]

Immunosuppressive (corticosteroids)

First line of treatment [8,9]

First line of treatment [24]

CSF Analysis

Treatment

68 The Open Ophthalmology Journal, 2012, Volume 6

relationship with polymyalgia rheumatica. Patients

may have jaw claudication, proximal myalgia and
arthralgia, scalp tenderness, headache, fatigue, and a
significantly increased erythrocyte sedimentation rate
and C-reactive protein level. Amaurosis fugax is a
threatening sign of impending arteritic AION. As
compared to NA-AION the vision loss is more severe
and the optic disc is pale. Temporal artery biopsy is
the gold standard for diagnosis of AION
[5,10,17,23,29,30].
-

Lebers Hereditary Optic Neuropathy (LHON)

involves sub-acute and painless visual loss with
central scotoma and poor color vision with sequential
involvement of both eyes over a period of weeks to
months. This disorder predominantly affects young
men (80%90%) and is inherited from maternal
mitochondrial DNA. Funduscopic examination
mainly shows circumpapillary telangiectasia, while
about 1/3 of patients primarily have a normal disc
appearance. Fat suppressed orbital MRI usually
shows enhancement of the optic nerve in ON, but not
so in AION or LHON [5,10,23].

Table 5.

Diagnostic Criteria for NMO [8,22]

Absolute criteria:

Optic Neuritis

Acute myelitis
Supportive criteria:

Brain MRI not meeting diagnostic criteria for MS

Spinal cord MRI that has T2 signal abnormalities extending over
three or more vertebral segments

NMO-IgG seropositive status

Toxins closely associated with optic neuropathy include

carbon monoxide, ethylene glycol, perchloroethylene, methanol, and tobacco. Drugs associated with optic neuropathy
are ethambutol, clioquinol, isoniazid, amiodarone, linezolid,
methotrexate, sildenafil, oxymetazoline, and infliximab.
Moreover, various chemotherapeutic agents are identified to
cause optic atrophy, including vincristine, cisplatin,
carboplatin and paclitaxel. Nutritional deficiencies such as
vitamin B12 in poor countries have a significant role in the
endemic optic neuropathy which deteriorates by tobacco use
[2,23].
Compressive optic neuropathies may be caused by sinus
mucocoeles, arterial aneurism, tumors, mass lesions, thyroid
eye disease or other orbital processes. Brain and orbital MRI
confirms or exclude diagnoses of compressive optic
neuropathy [2,16,18,23].
CLINICAL EXAMINATION
The clinical features of the patients specify the type of
examination required. Generally complete ophthalmic,
neurologic and systemic examinations should be performed
for diagnosis of ON [4,31].
Ophthalmic examinations including slit lamp examination
and pupillary reactions (RAPD) in unilateral or bilateral
asymmetric conditions allows a quantitative measurement of
whether the optic neuropathy is stable, improving, or

Hoorbakht and Bagherkashi

worsening [1,31,32]. Aided visual acuity (V.A) is measured

for near vision by near vision plates and for distance vision by
ETDRS (early treatment diabetic retinopathy chart) or retroilluminated Bailey-Lovie chart at a distance of 4m and Snellen
at 6m [31,32]. Those unable to read any letters at one meter
are further examined by counting fingers, identifying hand
movements or perceiving light [7]. Color vision, where V.A
and central visual function allows, can be recorded using FM100 hue test (Farnsworth Munsell 100) or Ishihara
pseudoisochromatic color vision plates [1,7,9]. Contrast
sensitivity can be recorded using Pelli-Robson charts at a
distance of 1m [7,31] or Cambridge low contrast gratings [32].
Low-contrast letter acuity (Sloan charts) and contrast
sensitivity (PelliRobson chart) show a strong relationship
with brain MRI and RNFL thickness, by OCT [2]. Visual field
determination, where aided V.A permits, recorded for both
eyes by Goldmann perimeter to evaluate peripheral visual
field and Humphrey field analyzer to evaluate central 30
degrees [7,31,32]. Fluorescein angiography and electroretinography (ERG) is done in case of retinal diseases [4].
Optical Coherence Tomography (OCT) is used to measure the
thickness of retinal tissues which are thinned in the affected
eye by ON [10,14,25,33,34]. Reduction in RNFL thickness
correlates with visual acuity, visual field, color vision, contrast
sensitivity and visual evoked potential (VEP) amplitude
[33,34].
Neurological examinations including orbital and brain
MRI is performed with or without gadolinium (Gd)
preferably within two weeks after the onset of symptoms
[9,10,32]. Contrast enhancement of the optic nerve is a
sensitive finding in acute ON but does not correlate with the
degree of visual recovery [8,16] (Fig. 1A).
In patients with atypical presentation, brain and orbital
MRI with Gd is compulsory and in typical ON this
procedure not only allows confirmation of the diagnosis but
is used as a prognosticator for developing clinically definite
MS (CDMS) [1,2]. Signal abnormalities are depicted by their
size (3 or <3 mm), location (periventricular or nonperiventricular), and shape (ovoid or non-ovoid). No signal
abnormality is categorized as grade 0; one or more focal
signal abnormalities, all of which are either smaller than 3
mm or non-periventricular and non-ovoid, as grade I; one
periventricular or ovoid signal abnormality at least 3 mm in
size, as grade 2; two such abnormalities as grade 3; and three
or more such abnormalities as grade 4 [35] (Fig. 1B). CT
scan with contrast is done when MRI is not possible [2,9].
Functional MRI (fMRI) has shown evidence of changed
pattern of activation of visual and some non-visual cortical
areas following ON [14]. VEP may be helpful in diagnosis
of subclinical cases with presentation of dyschromatopsia
and optic disc pallor, contralateral subclinical cases of ON
and suspected acute demyelinating ON. Abnormal results
such as increased latencies and reduced amplitudes of
waveform are compatible with demyelination in the afferent
visual pathways and are seen in more than 65% of patients
with ON. Multifocal VEP is more sensitive in detecting
demyelinating ON and pattern VEP followed by contrast and
Humphrey visual field is useful to identify fellow eye
abnormality [2,8,10,32,33].
According to the ONTT, patient with typical ON does
not require laboratory studies and lumbar puncture (LP)

Optic Neuritis, its Differential Diagnosis and Management

while in atypical ON careful examination is required to

establish the correct treatment regimen specifically in
children, bilateral cases or when systemic or infectious
diseases are in doubt [2,4,8,9].

The Open Ophthalmology Journal, 2012, Volume 6

69

TREATMENT
The goals of many of the existing and emerging
treatments including steroid and immuno-modulatory
therapy are reduction in the number and severity of attacks,
and prevention of axonal loss and subsequent disability in
both ON and MS [8].
Recovery of visual functions in ON is observed
spontaneously within 2-3 weeks in more than 80% of
patients without treatment. Vision stabilizes over months or
continues to improve up to 1 year, although long-term
defects in visual functions is possible [2,5,9,31,32].
According to the Optic Neuritis Treatment Trial (ONTT)
protocol, each patient was randomly assigned to receive one
of the following three regimens within 8 days after the onset
of symptoms: (1) oral prednisolone, 1 mg/kg per day for 14
days (prednisone group); (2) intravenous methylprednisolone
(IVMP) sodium succinate, 250 mg every 6 hours for 3 days,
followed by oral prednisone, 1 mg/kg per day for 11 days
(intravenous group); or (3) oral placebo for 14 days (placebo
group). Regimens for oral and intravenous prednisolone
groups were followed by a short tapering off with oral
dosages consisting of 20 mg of prednisolone on day 15 and
10 mg on days 16 and 18 [1,2,4,6,10,35].
ONTT and other studies showed that the high-dose
intravenous corticosteroids were effective in improving
short-term visual recovery particularly for visual fields and
contrast sensitivity as compared to oral prednisolone and
placebo, but the difference in the rate of recovery subsided
within 1 month and there was no statistically significant
benefit in long-term (1year) outcome among the three
groups. At 6 months, there was still a small statistically
significant benefit for the intravenous regimen in contrast
sensitivity, visual field, and color vision but not in visual
acuity [1-4,6,9,10,31,32,35].
Based on the ONTT findings, intravenous steroids
treatment is recommended when 3 or more signal
abnormalities are present on MRI and reduces risk of
developing MS by 2 years. It is also recommended in
patients in whom there is a need for faster recovery of visual
deficits (i.e., uniocular patients, employment demands,
bilateral involvement and patients desiring intervention)
[2,4,10,32].

Fig. (1). (A, B) MRI of brain and orbits in pateint with acute
demyelinating optic neuritis. Reprinted by permission from [N Engl
J Med 2006; 354: 1273-80. Copyright 2006 Massachusetts
Medical Society].

Systemic examination including CSF analysis consist of

determination of total protein, albumin, IgG, IgA, IgM,
glucose, lactate, cell count, microbiological/virological
analysis and oligoclonal bands. Oligoclonal banding of
proteins in CSF is a valuable predictor of the risk of MS.
Blood culture and serological tests must be done to rule out
infective and inflammatory cases such as SLE, syphilis and
sarcoidosis (biopsy of accessible tissue if applicable). Chest
X-ray and the Mantoux test is done in patients suspected to
tuberculosis before starting steroid treatment [4,9,10,18,31].

Visual Acuity: In the ONTT visual acuity at 1 year

was 20/40 or better in 95%, 94%, 91% in placebo,
IVMP and oral prednisone groups respectively [1,4].

79% and 93% of patients began to show enhancement of

vision within 3 and 5 weeks of onset, 93% (69%) showed
VA of >20/40 (>20/20) in the affected eye at 1 year and at
15 years follow up 72% (>92%) showed VA of
20/20
(20/40) in affected eye and 66% (1%) showed VA of
20/20
(<20/200) in both eyes respectively [2,4].
The risk ratio of normal visual acuity in the intravenous
group compared to placebo was 1.08 (95% CI 0.89 to 1.31)
at one month, 1.06 (95% CI 0.89 to 1.27) at six months and
1.06 (95% CI 0.92 to 1.22) at one year. The relative risk of
normal visual acuity in the oral group compared to placebo

70 The Open Ophthalmology Journal, 2012, Volume 6

was 0.95 (95% CI = 0.77 to 1.18) at one month, 0.93 (95%

CI = 0.76 to 1.13) at 6 months and 0.76 (95% CI = 0.63 to
0.92) at 1 year [3].
While good visual function recovery is reported in most
patients, approximately 5% to 10% of patients fail to recover
fully. Subtle symptoms such as blurred, washed out vision
may persist even in patients with VA of
20/20 [2,4,10].
-

Contrast sensitivity: The risk ratio of normal contrast

sensitivity in the intravenous group compared to
placebo was 1.06 (95% CI 0.95 to 1.17) at one month,
1.10 (95% CI 0.92 to 1.32) at six months, and 0.99
(95% CI 0.93 to 1.06) at one year. The relative risk of
normal contrast sensitivity in the oral group compared
to placebo was 1.00 (95% CI = 0.90 to 1.12) at one
month, 1.02 (95% CI = 0.83 to 1.25) at six months
and 0.93 (95%CI = 0.86 to 1.00) at one year [3].

Visual field: The pooled risk ratio of normal visual

field for the intravenous group compared to placebo
was 1.43 (95%CI 1.12 to 1.84) at one month, 1.08
(95% CI 0.96 to 1.22) at six months, and 1.02 (95%CI
0.86 to 1.20) at one year. The relative risk of normal
visual field for oral group compared to placebo was
1.16 (95% CI = 0.88 to 1.51) at one month, 1.00
(95%CI = 0.87 to 1.14) at six months and 0.94 (95%
CI = 0.79 to 1.12) at one year [3].

According to ONTT, RAPD may disappear when visual

recovery is full [2].
Raz et al. reported that visual form processing has a
quick (4months after onset of ON) and full recovery as
compared to visual motion [20].
Studies have shown IV dexamethasone (200 mg once
daily for three days) has equal effectivity as IVMP (as
recommended by ONTT) with fewer side effects, easier
administration and lower cost [4,31,32].
ONTT reported mild side effects of steroids such as
depression, acute pancreatitis, weight gain, sleep
disturbances, mild mood changes, stomach upset, facial
flushing, as well as serious side effects which were rare and
only happened in the IVMP group. Avascular necrosis of the
hip or other joints is a serious complication that rarely occurs
due to a brief course of corticosteroids. Other studies
reported hyperglycemia, constipation, diarrhea, acneiform
eruption, hyperlipidemia, headache and fever [3,8,35].

Hoorbakht and Bagherkashi

neurological impairment. DMDs are playing the role in

increasing the time to start the second episode, and the
incidence of subsequent MS relapses and demyelinating
lesions. The different mechanisms suggested include reduced
antigen presentation, inhibition of pro-inhibitory cytokines
and autoreactive T cells, induction of immunosuppressive
cytokines and reduced migration of cells in the CNS
[2,4,5,8,9].
Before assigning a patient to treatment with interferon, it
is important to consider that over 40% of patients with ON
and an abnormal MRI scan will not develop CDMS at
10years. In addition, to prevent one relapse patients need
treatment for approximately 6 years and finally the long-term
visual prognosis is desirable even if MS progresses. In the
USA patients are recommended to be referred to a
neurologist and have a discussion about DMDs therapy
while in the UK the policy remains that interferon- or
Copaxone are not started unless a second clinical attack
occur within 2 years after onset of ON [2,8].
CHAMPS (Controlled High-Risk Subjects Avonex
Multiple Sclerosis Prevention Study) was a randomized,
double blind assessment including 383 patients with an
early, acute mono symptomatic demyelinating event and at
least 2 silent T2 lesions on brain MRI. Within 27 days after
the onset of symptoms, patients were randomly assigned to
one of two treatment regimen: Initial treatment with IVMP
and an oral taper subsequent to weekly intramuscular
injections of 30 microgram of interferon -1a (Avonex).
Same initial treatment followed by weekly injections of a
placebo. The treatment group experienced a reduction in the
progression rate of CDMS compared to the placebo group
(35% vs 50 %) over 3 years of follow-up as well as valuable
effects on all MRI parameters, including decrease in T2
lesion development and volume, and gadolinium-enhancing
lesions. Patients treated quickly with interferon -1a after the
first attack, had a lesser chance of developing a second
episode within 10 years follow up compared to those who
had delayed treatment (after about 30 months). The most
common side effects of Avonex were flu-like symptoms
including myalgia, fever, fatigue, headache, chills, nausea,
vomiting, pain and asthenia [1,4,10].

Immunnomodulatory Therapy

In an Early Treatment of MS study (ETOMS), 308

patients with initial clinical demyelinating events (98 of
whom had acute optic neuritis) randomly received either 22
microgram weekly of interferon -1a (Rebif )
subcutaneously or placebo. Treatment was started within
three months of symptom onset; 39% of patients had two or
more CNS lesions at presentation. 70% of patients received
corticosteroids (variable dose and route of administration)
before interferon -1a. MS was found to be less developed in
patients who received interferon -1a compared to the
placebo group (34% vs 45%) with significantly fewer new
lesion formations on T2-weighted MRI at two years followup [10].

Since there is evidence of early axonal damage in acute

demyelinating ON, long term treatment with disease
modifying drugs (DMDs) such as interferon -1a (Avonex),
interferon -1b (Betaseron) and glatirimer acetate
(Copaxone) should be considered in patients at high risk of
developing MS as prophylaxis confronting permanent

The most recent study that used Betaferon in Newly

Emerging Multiple Sclerosis for Initial Treatment
(BENEFIT), reported reduction in risk of MS by 50% within
24 months in patients who had a single neurologic event and
at least 2 clinically silent MRI lesions after receiving
standard dose of Betaseron [4,10].

Intravenous immunoglobulin (IVIG) treatment and

plasma exchange show contradictory results in improvement
of visual function and reduction in rate of conversion to MS.
Uhthoffs symptoms are completely reversible and not
damaging to vision. They can be eased by staying indoors on
hot and humid days and drinking abundant cool fluids
[2,4,8,9].

Optic Neuritis, its Differential Diagnosis and Management

The Open Ophthalmology Journal, 2012, Volume 6

RISK OF RECURRENCE OF ON
Optic neuritis can occur as a monophasic or recurrent
disease, either in the same or the contralateral eye especially
in patients who develop MS thereafter. The ONTT reported
28% and 35% of patients recurred ON within 5 to 10 years
respectively [2,14]. At the 5 year follow-up, the relapse of
ON was 19% for the affected eye, 17% for the fellow eye
and 30% for either eye [1].
Treatment with oral prednisone alone in standard doses
increased the relapse rate of ON and therefore is not
recommended in acute typical ON (Table 6). Higher doses of
oral corticosteroids have shown the same recurrence rate
compared to placebo [1,3,6,8,10,32,35].
Table 6.

Recurrence Rate of ON [2,8,10]

71

diagnosis is carried out clinically, or atypical which

necessitates complete laboratory and neurological
examinations in accordance with ONTT recommendations to
discover the source of inflammation. Several conditions
present with identical symptoms as ON and they should be
considered for appropriate treatment. The majority of
patients with ON recover visual function spontaneously.
However, IVMP can accelerate the rate of recovery. Most
patients may experience some long-term visual defects even
after receiving treatment and achieving VA of 6/6. The less
expensive IV dexametasone treatment can be used as an
alternative to IVMP. If any demyelinating lesions are present
in MRI, the patient should consult a neurologist regarding
treatment with DMDs as prophylaxis to decrease the risk of
developing MS with close monitoring.
ACKNOWLEDGEMENT

50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%

44%

41%
30%

29%

311%

%
25% 25%

13%

The authors wish to express their gratitude to Dr.

Changiz Geula, Professor of Neuroscience, Director,
Laboratory for Cognitive and Molecular Morphometry
Cognitive Neurology and Alzheimer's Disease Center,
Northwestern University, Feinberg School of Medicine, who
was abundantly offered invaluable guidance which brought
this work to fruition.
CONFLICT OF INTEREST

16%

The author(s) confirm that this article content has no

conflicts of interest.
REFERENCES

2 years
Oral prednisolone

5 years
IVMP

10 years
Placebo

CONVERSION FROM ON TO M.S

The presence of demyelinating white matter lesions in
brain MRI scans, 3 mm or larger in diameter, ovoid, located
in periventricular areas of the white matter and radiating
toward the ventricular spaces has been identified as the
strongest predictor for the development of MS [2,4,5,10].
In addition to absence of MRI findings, being male,
having papillitis, VA of no light perception, absence of pain,
retinal exudates and peripapillary haemorrhages are related
to lower risk of developing MS. The risk of MS following
demyelinating ON is much lesser in children than adults and
estimated to be 13% at 10 years, 19% at 20 years and 26%
after 40 years [2,4].
According to ONTT, treatment with IVMP followed by
oral prednisone resulted in lower rates of developing MS in
the first 2 years, but this effect was not continuous after year
3. It showed 16% risk of MS development at 5 years with
normal brain MRI findings, 37% with 12 lesions and 51%
with
3 lesions. The only statistically significant difference
at 10 years was between no lesions (22% risk) and one or
more lesions (56% risk), which had increased to 25% and
75% respectively at 15 years [1,2,4,5,8-10,34,35].
CONCLUSION
The most common cause of acute optic neuropathy in
young women is ON which can be either typical, in which

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Accepted: June 20, 2012

Hoorbakht and Bagherkashi; Licensee Bentham Open.

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